Management Challenges Management Challenges inin

Primary & Secondary Primary & Secondary Eye Care in IndiaEye Care in India

Prof. R.S. GoyalProf. R.S. Goyal

Institute of Health Management Institute of Health Management Research, JaipurResearch, Jaipur

Eye care scenario in Eye care scenario in IndiaIndia Prevalence of blindness in India is Prevalence of blindness in India is

relatively large (0.7%) as compared relatively large (0.7%) as compared to world as a whole (0.57% ).to world as a whole (0.57% ).

Country has 15 – 18.6 million people Country has 15 – 18.6 million people with blindness accounting for one with blindness accounting for one fourth of the world’s blind populationfourth of the world’s blind population..

India has highest burden of India has highest burden of blindness in the world.blindness in the world.

Regional Burden of Regional Burden of Blindness (RBB)Blindness (RBB)

Region % of global

population (A)

% of global

blindness burden (B)

RBB (B/A)

Established Market Economies

15.1 6.3 0.41

Former Socialist Economies of Europe

6.6 2.9 0.44

India 16.1 23.5 1.46China 21.4 17.6 0.82Other Asia and Islands 13.0 15.3 1.18Sub-Saharan Africa 9.7 18.8 1.93Latin America and the Caribbean

8.4 6.1 0.72

Middle-Eastern Crescent 9.6 9.5 0.99

Recent trends indicates that Recent trends indicates that prevalence of blindness due to prevalence of blindness due to infectious diseases is decreasing, but infectious diseases is decreasing, but age-related impairment is growing. age-related impairment is growing.

Around 82 % blind people are above Around 82 % blind people are above 50 years of age.50 years of age.

Visual impairment is relatively Visual impairment is relatively higher among women ( in all ages) higher among women ( in all ages) than males.than males.

Cataract has been recognized as the major Cataract has been recognized as the major cause of blindness in the country. cause of blindness in the country.

Around 3.8 million people become blind Around 3.8 million people become blind due to cataract every year. It is also the due to cataract every year. It is also the leading cause of blindness, globally.leading cause of blindness, globally.

Under the current demographic scenario Under the current demographic scenario (rapid aging of population), it is feared (rapid aging of population), it is feared that prevalence of visual impairment in that prevalence of visual impairment in India will further increase in coming India will further increase in coming years.years.

There are also regional imbalances in There are also regional imbalances in prevalence of blindness across states in prevalence of blindness across states in India.India.

Status of prevalence of Status of prevalence of blindness in states of blindness in states of IndiaIndia

Category Prevalence (%) States & regions of the country

Low Prevalence < 1 Punjab, Himachal Pradesh, Delhi, West Bengal, & N.E.States

ModeratePrevalence

1 to 1.49 Gujarat, Haryana, Kerala, Bihar, Karnataka, AndhraPradesh and Assam

High Prevalence 1.5 to 1.99 Maharashtra, Orissa, Tamil Nadu & Uttar Pradesh

Very High Prevalence 2 and above Madhya Pradesh, Rajasthan and Jammu & Kashmir

Current status of eye Current status of eye care in Indiacare in India The The National Program of Control of National Program of Control of

Blindness Blindness ( NPCB) was launched in the ( NPCB) was launched in the year 1976 as a 100 percent centrally year 1976 as a 100 percent centrally sponsored program.sponsored program.

The objectives of NPCB include;The objectives of NPCB include; To provide high quality of Eye CareTo provide high quality of Eye Care To expand coverage of eye care servicesTo expand coverage of eye care services To reduce backlog of blindnessTo reduce backlog of blindness To develop institutional capacity for eye To develop institutional capacity for eye

care services.care services.The program also extended assistance to voluntaryThe program also extended assistance to voluntary

organizations for cataract operations and eye organizations for cataract operations and eye bankingbanking..

The NPCB sought to bring down The NPCB sought to bring down prevalence of blindness in the prevalence of blindness in the country to 0.3 % by 2010 by country to 0.3 % by 2010 by promoting ;promoting ; 1. Cataract Operations1. Cataract Operations

2. School Eye Screening ( Preventive measures 2. School Eye Screening ( Preventive measures & &

Screening Program)Screening Program)

3. Eye bank3. Eye bank

4. Strengthening of Infrastructure4. Strengthening of Infrastructure

5. Operationalization of Tele-Ophthalmic Vision 5. Operationalization of Tele-Ophthalmic Vision

CentersCenters

6. Capacity Building6. Capacity Building

A global  initiative A global  initiative Vision  2020:  The  Vision  2020:  The  right  to sight”right  to sight”

by WHO & IAPB to eliminate avoidable by WHO & IAPB to eliminate avoidable blindness by the year 2020, was launched blindness by the year 2020, was launched in India in 1999in India in 1999..

Its strategy focused on;Its strategy focused on;

disease prevention and control, training of disease prevention and control, training of personnel, strengthening of the existing personnel, strengthening of the existing eye care infrastructure, use of appropriate eye care infrastructure, use of appropriate and affordable technology and, and affordable technology and, mobilisation of resources.mobilisation of resources.

Goals and strategy of NPCB and Vision Goals and strategy of NPCB and Vision 2020 complemented each other in India.2020 complemented each other in India.

A host of international NGOs are A host of international NGOs are contributing to Eye Care in India. These contributing to Eye Care in India. These include; include; Sight Savers International, Christoffel-Sight Savers International, Christoffel-

Blindenmission (CBM), ORBIS International, Blindenmission (CBM), ORBIS International, Operation Eyesight Universal, Rotary Operation Eyesight Universal, Rotary International, International Eye Foundation, International, International Eye Foundation, Lions Clubs International Foundation, Help Age Lions Clubs International Foundation, Help Age India, Seva Foundation and many others.India, Seva Foundation and many others.

L.V. Prasad Eye Institute, HyderabadL.V. Prasad Eye Institute, Hyderabad Sankara Nethralaya, ChennaiSankara Nethralaya, Chennai Arvind Eye Care SystemArvind Eye Care System All India ophthalmological SocietyAll India ophthalmological Society Eye Bank Association of IndiaEye Bank Association of India Venu Eye Institute and Charitable Venu Eye Institute and Charitable

SocietySociety

are some of the leading national NGOs are some of the leading national NGOs

providing primary and secondary eye care providing primary and secondary eye care in India. in India.

NPCB supported a large increase in the NPCB supported a large increase in the infrastructure for eye care in the infrastructure for eye care in the country-country-

Regional Institute of Ophthalmology, Eye Regional Institute of Ophthalmology, Eye Banks , Mobile Units, up gradation of Banks , Mobile Units, up gradation of PHCs,PHCs, construction of Eye Wards and construction of Eye Wards and dedicated Eye OTsdedicated Eye OTs etc. etc.

The NPCB has also established The NPCB has also established 590 590 District Blindness Control Societies District Blindness Control Societies (DBCS) to strengthen the eye care (DBCS) to strengthen the eye care delivery at the district level. delivery at the district level.

NPCB gave particular emphasis on NPCB gave particular emphasis on promoting cataract surgeries in the promoting cataract surgeries in the country.country.

Yet, voluntary and private sectors are Yet, voluntary and private sectors are shouldering the major burden of corrective shouldering the major burden of corrective eye surgeries (65%) in the country. eye surgeries (65%) in the country.

About 11,000 ophthalmologists and an About 11,000 ophthalmologists and an equal number of trained and recognized equal number of trained and recognized mild level personnel (MLP) are currently mild level personnel (MLP) are currently available in the country against the desired available in the country against the desired ratio of at least 4‐5 MLP for each ratio of at least 4‐5 MLP for each ophthalmologist. ophthalmologist.

Nearly half of the ophthalmologists in the Nearly half of the ophthalmologists in the country are surgically inactivecountry are surgically inactive..

The ophthalmologist to population The ophthalmologist to population ratio in urban India is 1:25,000 but ratio in urban India is 1:25,000 but in rural India it is about 1:250,000.in rural India it is about 1:250,000.

Yet a Yet a rapid assessment rapid assessment in 14 in 14 districts in the country has pegged districts in the country has pegged the coverage of eye care services at the coverage of eye care services at around 70%.around 70%.

Also, IOL implantation rates gone up Also, IOL implantation rates gone up to 90% ( of all surgeries) in 2006‐07.to 90% ( of all surgeries) in 2006‐07.

The number of cataract surgeries The number of cataract surgeries performed has grown to 5 million in a performed has grown to 5 million in a year. A rapid assessment (2001-2) of year. A rapid assessment (2001-2) of the coverage of surgical the coverage of surgical interventions for cataract blind interventions for cataract blind shows 70% reach.shows 70% reach.

There are also evidence of improving There are also evidence of improving visual outcomes as assessed by the visual outcomes as assessed by the rapid assessment surveys among rapid assessment surveys among cataract operated.cataract operated.

Issues in childhood Issues in childhood blindness..blindness.. Specific infrastructure for detection Specific infrastructure for detection

and management of childhood and management of childhood blindness is not available at most blindness is not available at most primary and secondary health care primary and secondary health care facilities in the country.facilities in the country.

Human Resources particularly the Human Resources particularly the trained personnel are inadequate at trained personnel are inadequate at the PHC/CHC level.the PHC/CHC level.

At the tertiary level, very few centers (both At the tertiary level, very few centers (both Govt. and NGO) are equipped to manage Govt. and NGO) are equipped to manage childhood blindness.childhood blindness.

Because of inadequate trained ophthalmic Because of inadequate trained ophthalmic human resources, many conditions like human resources, many conditions like ocular injuries are treated by non‐ocular injuries are treated by non‐ophthalmologists like general surgeons or ophthalmologists like general surgeons or physicians in most places.physicians in most places.

Posterior segment care is grossly Posterior segment care is grossly inadequate. Only 150 ophthalmologists inadequate. Only 150 ophthalmologists (including govt. and private sector) are (including govt. and private sector) are trained to deal with posterior segment trained to deal with posterior segment disorders.disorders.

From a Socio‐economic From a Socio‐economic Perspective..Perspective.. There is a bias in the reach of cataract There is a bias in the reach of cataract

services. The urban, literate population services. The urban, literate population is getting a better coverage. is getting a better coverage.

Lack of escort/care providers, fatalistic Lack of escort/care providers, fatalistic attitude and fear in spite of increased attitude and fear in spite of increased commonness of services, and long commonness of services, and long waiting in decision making to undergo waiting in decision making to undergo surgery in the average Indian surgery in the average Indian household are also important barriers.household are also important barriers.

The Gender Issues..The Gender Issues..

Several studies have shown that the Several studies have shown that the female carry a 40% higher burden of female carry a 40% higher burden of cataract than the male. cataract than the male.

However, women access/use of cataract However, women access/use of cataract corrective services is either less or at the corrective services is either less or at the best equal to men. best equal to men.

To achieve equity in the backlog, there is To achieve equity in the backlog, there is a need to ensure that 60% of all cataract a need to ensure that 60% of all cataract surgeries are performed on women.surgeries are performed on women.

Challenges in Blindness Challenges in Blindness Control in IndiaControl in India A strategic approach to program A strategic approach to program

management is missingmanagement is missing Isolated efforts by the private, Isolated efforts by the private,

voluntary and public sectorsvoluntary and public sectors Poor balancing between the quantity Poor balancing between the quantity

and quality of careand quality of care Deficiencies in the cycle of careDeficiencies in the cycle of care In appropriate utilization of existing In appropriate utilization of existing

facilitiesfacilities

Lack of trained human resources and Lack of trained human resources and their unequal distribution in rural and their unequal distribution in rural and urban areasurban areas

Large gap in ophthalmic training & Large gap in ophthalmic training & educationeducation

Socio‐cultural, logistic and financial Socio‐cultural, logistic and financial issuesissues

Lack of general seriousness towards Lack of general seriousness towards the eye care the eye care

Low level of awareness for eye care in Low level of awareness for eye care in the community the community

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Strategic Management Strategic Management Process for Eye Care Process for Eye Care interventionsinterventions

Priority areas for Priority areas for Strategic Management of Strategic Management of Eye CareEye Care Comprehensive BCC / IEC strategy for eye Comprehensive BCC / IEC strategy for eye

carecare Capacity building of existing human Capacity building of existing human

resourcesresources Increase uptake in eye care training Increase uptake in eye care training

institutions through expanding institutions through expanding infrastructure for addressing HR shortageinfrastructure for addressing HR shortage

Formulate efficient PPP model using SWOT Formulate efficient PPP model using SWOT analysis of Government and Private sectoranalysis of Government and Private sector

Develop quality norms for primary Develop quality norms for primary and secondary eye care and and secondary eye care and procedures ensuring adherence for procedures ensuring adherence for quality controlquality control

Efficient MIS to be developed for Efficient MIS to be developed for quality implementation and quality implementation and monitoring of eye care interventionsmonitoring of eye care interventions

Evaluate the interventions based Evaluate the interventions based upon baseline and goals envisagedupon baseline and goals envisaged

Suggested areas for Suggested areas for efficient management of efficient management of NPCBNPCB Proper completion of Surgical Proper completion of Surgical

Records for cataract surgery and Records for cataract surgery and other services needs to be other services needs to be maintained with complete, correct maintained with complete, correct and reliable information;and reliable information;

Standard referral cards from Standard referral cards from primary to secondary/tertiary level primary to secondary/tertiary level of care;of care;

Development of Management Information Development of Management Information Systems at various levels so as to plan, Systems at various levels so as to plan, monitor and evaluate the programme in monitor and evaluate the programme in an efficient manner;an efficient manner;

Network of Sentinel Surveillance Units to Network of Sentinel Surveillance Units to be established to study profile of be established to study profile of beneficiaries and outcome of beneficiaries and outcome of interventions;interventions;

Independent evaluation on various Independent evaluation on various programme activities and outcomes with programme activities and outcomes with standard protocols comparable with standard protocols comparable with other nations.other nations.

PEC through PHC PEC through PHC

11.. Better nutritionBetter nutrition--Prevents vitamin A Prevents vitamin A deficiencydeficiency

22. Safe drinking water and sanitation . Safe drinking water and sanitation programmesprogrammes-- Contribute to trachoma Contribute to trachoma controlcontrol

3.Quality 3.Quality maternal and child health maternal and child health carecare--Reduce retinopathy of Reduce retinopathy of prematurityprematurity

4.4. Health education Health education--Prevention of eye Prevention of eye traumatrauma

Effective management of Effective management of eye care programs in eye care programs in outreachoutreach Strong leaders who build vision, Strong leaders who build vision,

commitment, positive attitudes, and a commitment, positive attitudes, and a sense of missionsense of mission

Increasing the uptake for eye care Increasing the uptake for eye care services through outreach and demandservices through outreach and demand

Generation activities, health education, Generation activities, health education, and social/service marketingand social/service marketing

Quality and size of human and other Quality and size of human and other infrastructure resourcesinfrastructure resources

Quality and number of instruments, Quality and number of instruments, equipment and suppliesequipment and supplies

Systems and procedures that Systems and procedures that optimizes the utilization of all of the optimizes the utilization of all of the above resourcesabove resources

Efforts required for Efforts required for preventive Eye Carepreventive Eye Care

Increased availability and affordability of Increased availability and affordability of eye care services; eye care services;

Increased commitment to prevention from Increased commitment to prevention from national program leaders, medical national program leaders, medical professionals and private and corporate professionals and private and corporate partners; partners;

Creation of awareness for increased use of Creation of awareness for increased use of eye health care services;eye health care services;

Implementation of effective eye care Implementation of effective eye care strategies to eliminate infectious causes of strategies to eliminate infectious causes of vision loss. vision loss.

RecommendationsRecommendations

Collaborative approach is required from Collaborative approach is required from Government and private sector to achieve Government and private sector to achieve the NPCB and Vision 2020 goalsthe NPCB and Vision 2020 goals

Government may focus on increasing Government may focus on increasing outreach services and providing primary eye outreach services and providing primary eye care services at PHCs while Private sector care services at PHCs while Private sector may focus on quality secondary eye caremay focus on quality secondary eye care

Efficient PPP models may be developed after Efficient PPP models may be developed after mapping of present facilities and need mapping of present facilities and need assessmentassessment

Strengthening of preventive eye care Strengthening of preventive eye care through school screenings, awareness through school screenings, awareness and community participationand community participation

Minimum quality norms should be laid Minimum quality norms should be laid down for government and private eye down for government and private eye care facilitiescare facilities

Capacity building of medical & Capacity building of medical & paramedical staff for primary eye careparamedical staff for primary eye care